What is the appropriate workup for a patient presenting with testicular pain?

Workup for Testicular Pain

Immediate Clinical Assessment

For any patient presenting with acute testicular pain, the primary goal is to rapidly exclude testicular torsion through focused history, physical examination, and urgent Duplex Doppler ultrasound, as this surgical emergency requires intervention within 6-8 hours to prevent testicular loss. 1

Key Historical Features to Elicit

• Onset and timing of pain: Abrupt, severe onset suggests torsion, while gradual onset indicates epididymitis 1
• Duration of symptoms: Critical for determining testicular viability (6-8 hour window for torsion) 1, 2
• Associated symptoms: Nausea and vomiting favor torsion 1, 3
• Age of patient: Torsion has bimodal distribution (neonates and postpubertal boys), while epididymitis is more common in adults over 25 years 1

Physical Examination Findings

Calculate the TWIST score to stratify risk before imaging 1, 3:

• Testicular swelling (2 points)
• Hard testis (2 points)
• Absent cremasteric reflex (1 point)
• Nausea/vomiting (1 point)
• High-riding testis (1 point)

Risk stratification based on TWIST score 1, 3:

• Score 0: Low risk (negative predictive value 100%) - torsion can be excluded without ultrasound
• Score 1-5: Intermediate risk - urgent Duplex Doppler ultrasound required
• Score 6-7: High risk (positive predictive value 93.5%) - proceed directly to surgical exploration without delaying for imaging

Diagnostic Imaging Algorithm

US Duplex Doppler of the scrotum is the initial imaging modality of choice 4, 1:

Components of the ultrasound examination 1:

• Grayscale examination: Assess testicular homogeneity and identify the "whirlpool sign" of twisted spermatic cord (96% sensitivity)
• Color Doppler assessment: Evaluate testicular perfusion (96-100% sensitivity for decreased/absent blood flow)
• Power Doppler: Particularly useful for prepubertal testes with slow flow
• Comparison with contralateral testis: Use as internal control

Critical ultrasound findings by diagnosis 4, 1:

Testicular torsion:

• Decreased or absent blood flow to affected testicle
• "Whirlpool sign" of twisted spermatic cord (most specific finding)
• Enlarged heterogeneous hypoechoic testis
• Ipsilateral hydrocele and scrotal skin thickening

Epididymitis/epididymo-orchitis:

• Enlarged epididymis with increased blood flow on Doppler
• Scrotal wall thickening and hydrocele common
• Up to 20% concomitant orchitis rate 4

Torsion of testicular appendage:

• Normal testicular perfusion
• "Blue dot sign" (pathognomonic but only present in 21% of cases) 1

Critical Management Decisions

When to bypass imaging and proceed directly to surgery 1, 5, 2:

• TWIST score 6-7 (high risk)
• Clinical presentation strongly suggestive of torsion with immediate surgical availability
• Any delay in imaging that would exceed the 6-8 hour window

Immediate urological consultation is mandatory when 1, 5:

• Physical findings do not confidently exclude testicular torsion
• Intermediate or high TWIST score
• Any acute scrotal pain where torsion cannot be definitively ruled out clinically

Age-Specific Differential Diagnosis Considerations

Prepubertal boys 1:

• Most common: Torsion of testicular appendage
• Consider: Testicular torsion (neonatal peak)

Adolescents and young adults 1, 2:

• Most common: Testicular torsion (postpubertal peak, 3.8 per 100,000 males <18 years annually)
• Consider: Epididymitis, torsion of appendage

Adults >25 years 1:

• Most common: Epididymitis/epididymo-orchitis (600,000 cases annually in US)
• Testicular torsion rare after age 35

Additional diagnoses to consider 4, 1:

• Segmental testicular infarction: Wedge-shaped avascular area on ultrasound
• Acute idiopathic scrotal edema: Self-limiting, marked scrotal wall thickening, painless
• Scrotal fat necrosis: Prepubescent boys with cold exposure, hyperechoic caudal scrotal fat

Common Pitfalls to Avoid

• Normal urinalysis does not exclude testicular torsion or epididymitis 1
• False-negative Doppler evaluations can occur with partial torsion or spontaneous detorsion 1
• Do not delay surgical exploration for imaging in high-risk patients, as testicular salvage rates decline significantly after 6-8 hours 1, 2
• Significant overlap exists in clinical presentation between different causes of acute scrotal pain 1
• Partial torsion (>450 degrees) may present with less severe symptoms but still requires surgical intervention 1

Additional Workup for Non-Emergent Cases

For patients with chronic testicular pain (≥3 months duration) where acute pathology is excluded 6:

• Consider spermatocele, tumor, varicocele as reversible causes
• Recognize that pain may involve epididymis, vas deferens, or paratesticular structures
• Spermatic cord block can predict response to microdenervation